Doc, Can You Remove the Excess Skin from the Sides of My Upper Lids?

In patients who have excess upper eyelid skin (dermatochalasis), the amount of excess skin tends to be more on the lateral side. This can be caused by several factors but two of the main ones are loss of the lateral fat pad with age (leading to loss of support for the skin) and drooping of the eyebrows. During surgery, it is important to remove this lateral skin; otherwise these excess skin (known as lateral hooding) can make the patients appear old and sad. Patients who had had surgery performed in beauty centres or by less experienced surgeons often fail to have these problems addressed because the operators were concerned about leaving behind scars beyond the double eyelids. However, when done properly, these extended lines beyond the double eyelids usually resolve within a few weeks.

This middle-aged woman underwent upper eyelid surgery in another centre seven months ago. She was unhappy with the result because of lateral hooding. On examination, her eyebrows were at the normal position and therefore lifting the eyebrows is not appropriate in this case. She was offered two options: a. excision of the skin below the eyebrows to lift the excess skin; or b. remove the excess skin directly. She opted for the later option because the heights of the double eyelids are also asymmetrical. 



Excess upper eyelid skin drooping over the lateral sides of

the eyelids (lateral hooding).

Patient also has unequal double eyelid heights.

Excision of the skin below the eyebrows can lift

the excess skin.

The excess skin can be removed by directly removing

the excess skin.

Extended upper eyelid blepharoplasty was performed together

with recreations of the upper eyelids .

The appearance of the eyes at one weeks, the scars beyond

the double eyelids have begun to fade.

The following pictures show another patient who underwent dermatochalasis (excess upper eyelid skin) operation using the extended upper blepharoplasty technique. The scars faded after 14 days.

A patient with excess upper eyelid skin and significant

lateral hooding.

Extended upper blepharoplasty was performed.

The wounds beyond the double eyelids were sutured with

nylon for better results.

Appearance of the eyes at 14 days, the scars have faded.

Are Oculoplastic Patients Vain?

Most people assume oculoplastic surgeons deal mainly with patients who are vain as shown by this humourous poem below (from Survey of Ophthalmology).

A Resident's Lament (Akshay Gopinathan Nair MBBS, Michael F. Marmor MD)

As I study now to be an eye MD,
I ask what kind of doc I want to be.
It is a rather daunting question
That raises fear and apprehension,

As each eye part has its own specialty!
Should retina be the field in which I train
To find a tear or subtle new membrane?
But I seem to give my patients aches
When I indent to find their breaks
And that just makes for too much mental strain.

Perhaps it should be neuro-ophthalmology:
The optic nerve, its path, and its pathology.
But when there’s pallor, one asks Why?
With CT, PET, and MRI …
So why not just go into radiology?

My surgery could be limited to refractive.
I’d soon build up a practice, very active.
Though YAGs and excimers do magic
The odd myopic surprise is tragic:
On balance this may not be so attractive.

Then how about procedures oculoplastic
On skin that is no longer so elastic?
But operative hours are long (a pain),
And patients they are, oh, so vain.
It’s hard not to say something too sarcastic.
Perhaps glaucoma is the field to choose,
Though pressures, fields, and angles do confuse:
Does pressure cause the nerves to die,
Or sick nerves yield when pressure’s high?
I’d like a field where fewer patients lose.

Strabismus is another possibility,
To repair defects in the eye’s motility.
But waiting rooms with children crying
Would, in time, become quite trying
(From residency right through to my senility).

With so much then to learn, is it reality
To limit oneself to only one modality?
The eye is wondrous and diverse!
I think I’ll embrace, for better or worse,
The field of ophthalmology in totality.

Although most of my private patients are concerned with double eyelids and eyebags; a large proportion of my patients seen in the Sarawak General Hospital are concerned with non-cosmetic eyelid conditions such as eyelid tumours and eyelid malpositions referred from all over Sarawak. A recent example is this patient who developed a right cicatricial ectropion (retraction of the eyelid as a result of scarring) after facial infection.

Retraction of the left lower eyelid as a result

of facial scarring.

Steps used to correct the retraction.

Appearance of the eyelids at second week

post-operative.

Doctor, Why are My Double Eyelids Unequal? Part III

Another important cause of unequal double eyelid height is due to unequal removal of the eyelid skin. This is especially common in older patients with excess skin, the eye where less skin is removed will result in the eyelid hanging over the double eyelid making the double eyelid appears lower.

The picture on the left shows equal amount of skin to be removed is marked whereas the picture on the left shows that the left upper eyelid has more skin being marked for removal.

This woman underwent a double eyelid surgery in a beauty saloon. Unfortunately, the left double eyelid appeared lower than the right (right picture). She went back to look for the "surgeon" but was told that she had returned to China without forwarding address or telephone. Examination showed that more skin had been removed in the right than the left eye. Revision was carried out by removing the excess left upper eyelid skin.

Doctor, Why Are My Double Eyelids Unequal? Part II

Case 1. A patient who had double eyelid surgery done

elsewhere. Left skin crease higher than the right.

Case 2. Another patient with a higher left skin crease

performed elsewhere.

As mentioned in the previous blog double eyelid (skin crease) asymmetry is one of the most common complaints from the patients undergoing double eyelid surgery. Unequal skin markings before the operations is an important cause of the asymmetry and to avoid this:

a.  It is important to mark the skin prior to any anaesthetic injections to avoid distortion of the tissue.

b. In addition, double eyelid surgery should be postponed if there is any eyelid swelling which again can distort the tissue for symmetrical markings.

c. During the markings, the measurement should be precise and ideally a caliper (as shown in the picture) should be used rather than a ruler.

d. Another important thing to remember during markings is to ensure that the skin of the eyelids are under equal tension (see pictures below).

The marking is done with a caliper with the eyelid skin

under tension by pulling on the eyebrow.

Marking with a caliper with the eyelid relaxed. Note that the

marking, even though marked at 6mm as the picture above,  

produce a line higher than when the skin is under tension.

Doctor, why are my new double eyelids unequal?

Several studies looking into the complications and patient dissatisfaction of double eyelid surgery found that unequal double eyelids (asymmetry of the skin creases) is one of the most common complaints (see references below). While unequal double eyelids are common immediately after double eyelid surgery, their persistence beyond 4 weeks should be regarded as permanent. Patients who have significant unequal double eyelids (more than 1 mm different) often seek help to address the imbalance. 

This 38 year-old underwent double eyelid surgery in a beauty saloon using the suture technique. The procedure was performed by a "doctor" from China of dubious qualification. Post-operatively, she noticed significant unequal double eyelids. Despite repeated reassurance from the beauty saloon owner, the asymmetry remained 8-week post-operative. Unfortunately, the surgeon had since gone and could not be contacted.

The three possible causes of this deformity noted were:

a.       The difference in measuring and marking the skin for suturing or incision

b.      Different skin tension while doing supratarsal fixation and

c.        Differing widths of skin excision in upper eyelids.

References:

1. Strategies for a successful corrective Asian blepharoplasty after previously failed revisions. Chen SH, Mardini S, Chen HC, Chen LM, Cheng MH, Chen YR, Wei FC, Weng CJ. Plast Reconstr Surg. 2004 Oct;114(5):1270-7; discussion 1278-9.
2. Complications of Oriental blepharoplasty. Weng CJ, Noordhoff MS. Plast Reconstr Surg. 1989 Apr;83(4):622-8.
3. Unfavorable results in Oriental blepharoplasty. Hin LC. Ann Plast Surg. 1985 Jun;14(6):523-34. No abstract available.

Asymmetry of skin creases are common amongst attractive faces.

One of the most common cause of dissatisfaction after double eyelid surgery (Asian blepharoplasty) is unequal height of the double eyelids (skin creases). However, even in the best of hands, the lines created are likely to be slightly unequal in height and provided the difference is slight most patients can be persuaded to accept the results. In fact, it is worth noting that amongst models and film stars who are perceived as attractive, asymmetry of skin creases are common (see pictures above).

In the next article, I will discuss the causes for unequal double eyelids after surgery and ways to restore the symmetry.

Unequal double eyelids may be mistaken for droopy eyelids.

An eyelid without double eyelid may appear smaller because of the overhanging eyelid. (see why double eyelid makes the eye bigger?) If one eye has double eyelid and the other absent double eyelid, the later may be mistaken for droopy eyelid. I have come across a few patients who were referred to me for droopy eyelid when in fact the problem is absent of double eyelid in the smaller eye and the treatment of choice is to create a double eyelid. There are several ways of doing these either with non-surgical method (glue or tape) or surgery (both suture technique or incision technique).

Right eye appears to have droopy eyelid due to poorly

formed double eyelid. Creation of double eyelid balances

both eyelids.

Right eye appears droopy due to absent double eyelid.

When the double eyelid is created with tape the two

eyes appear the same size.

Below is the article which I recently published in Malaysian Journal of Medicine highlighting this condition:

Challenges in Diagnosis and Management of Pseudoptosis Secondary to Asymmetrical Skin Creases